Cholangioscopy-guided lithotripsy vs. conventional therapy for difficult bile duct stones: An observational cohort study

Aims Although endoscopic retrograde cholangiopancreatography (ERCP) is the main treatment of common bile duct (CBD) stones, succeeding clearance of the CBD in the majority of cases, the presence of difficult stones can limit its results. Cholangioscopy-guided lithotripsy has recently offered encouraging results in difficult CBD stone removal. Aim of our study was to compare cholangioscopy-guided lithotripsy vs. conventional therapy for difficult bile duct stones treatment.

Methods This is an observational study, from January 2020 to October 2023, including all patients with difficult CBD stones, defined as a stone diameter≥10mm and/or multiple stones of distal CBD.

Results Totally 333 patients were included (M/F: 162/171, mean age 62±14.5 [22-90] years). Out of 333 ERCPs, 141 patients (42.3%) were admitted with difficult CBD stones. The mean age of the patients was 63±13.5 years. We performed a large sphincterotomy (LS) alone in 53 patients (37.5%) and an endoscopic papillary balloon dilation at 13mm (EPBD) after an endoscopic sphincterotomy (EST) was performed in 22 patients (15.6%). The first session successful endoscopic clearance rate of LS and the combination of EST and EPBD were 75.5% (40/53) and 72.7% (16/22) respectively. In 66 separate cases, in addition with those 19 cases that both previous techniques failed, we performed cholangioscopy and electrohydraulic lithotripsy with a success rate (SR)>96% (82/85). The remaining 3 cases underwent a second cholangioscopy after plastic stenting in order to be fully treated. No complication of EPBD, LS or EHL was reported during the 24-hour hospitalization.

Conclusions Cholangioscopy-guided lithotripsy was superior (p=0.00006) compared to conventional therapy for the treatment of difficult bile duct stones. Cholangioscopy-guided lithotripsy not only constituted an effective assist for difficult CBD stones after EPBD or LS, but also achieved a high first session successful endoscopic clearance rate (>96%). Cholangioscopy is a technique that should be widely performed due to its high SR and low complication rate.

Publication History

Article published online:
15 April 2024